Failure to Develop ADL Care Plan and Provide Nail Care
Penalty
Summary
The facility failed to develop a comprehensive, person-centered ADL care plan for one resident who required assistance with personal care. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus without complication, a stage 2 sacral pressure ulcer, COPD, need for assistance with personal care, lack of coordination, muscle wasting and atrophy of the right shoulder, major depressive disorder, generalized anxiety disorder, peripheral vascular disease, hypertensive heart disease with heart failure, personal history of venous thrombosis and embolism, obstructive sleep apnea, and obesity. Physician orders dated 12/24/2025 specified that the resident required one-person assistance with ADLs, but review of the comprehensive care plan showed no evidence that this ADL assistance need was addressed. On multiple observations, the resident’s fingernails were noted to be long with a dark brown grimy substance under the nails on both hands, and during an observation with the S2DON, the S2DON confirmed the fingernails needed to be cleaned and trimmed. In an interview, the S2DON confirmed that no ADL care plan had been developed for this resident and that there was no care plan specifying who would trim and clean the resident’s fingernails or how often nail care would be provided. This deficiency centers on the omission of an ADL-focused care plan despite documented orders for assistance and observable unmet personal care needs, specifically nail care, for a resident with significant medical and functional conditions.
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